Megan McArdle, after reading an article in The New York Times, wonders if “disruptive doctors actually account for a notable percentage of medical errors.”

This New York Times article suggests that doctor arrogance is a significant cause of medical error. I certainly wouldn’t be shocked if this were true. Still, given the thinness of the data, I have to wonder:

“A survey of health care workers at 102 nonprofit hospitals from 2004 to 2007 found that 67 percent of respondents said they thought there was a link between disruptive behavior and medical mistakes, and 18 percent said they knew of a mistake that occurred because of an obnoxious doctor. (The author was Dr. Alan Rosenstein, medical director for the West Coast region of VHA Inc., an alliance of nonprofit hospitals.)”The observation that some people are jerks, and that jerkiness does not enhance performance, is not exactly surprising. What I want to know is whether disruptive doctors actually account for a notable percentage of medical errors. I’m sure if you surveyed doctors, 20% or so could report an error caused by a lazy LPN, incompetent PA, or pigheaded nurse. But I’m skeptical that “nurse pigheadedness” is actually a major problem that America’s healthcare system needs to address.

There are lots of arrogant doctors out there, but I’m not sure how often this translates into medical errors. The doctors I know who are the biggest jerks aren’t necessarily any worse at practicing medicine than other doctors. Of course I tend to send my referrals to others for obvious reasons.

Whether this results in more errors is a different matter. If a doctor is so arrogant that they won’t follow protocols to ensure that the correct body part is labeled for a surgery, then it certainly is plausible that this could lead to errors. Going by anecdotal evidence can also magnify the problem. A nurse witnessing surgery being performed on the wrong body part by an arrogant doctor is certainly going to remember this episode, and might unintentionally over-estimate the frequency of such episodes compared to other medical errors.

Megan wonders about “nurse pigheadednesss.” To some degree this is a problem. I have had cases where nurses failed to give blood pressure pills or insulin because the blood pressure or sugar was normal. Of course they were normal because they were on these medications, and failure to give the ordered medications resulted in loss of control. Realistically this type of situation does not generally cause serious long term harm (but could cause me to complain in a manner which the nurses causing the problem might see as arrogant). I also fear that doctors who are jerks contribute to some problems with nurses. Nurses who are reluctant to call me in the middle of the night with a change in a patient are probably reluctant because of being yelled at by the handful of doctors foolish enough to do this. It is far better to take a call at 3:00 a.m. when a patient is just starting to deteriorate than to be surprised when doing rounds the next day.

The real pigheadedness which perpetuates many hospital problems is “administrator pigheadedness.” That’s the belief by many hospital administrators that their hospital is run perfectly and that anyone who complains must be an arrogant physician or troublemaker. Some medical errors are caused by isolated mistakes by the people involved. Far too many medical errors are caused by systems errors. The climate for fixing such errors is better now than it was ten to twenty years ago, but I still see too many errors persisting due to “administrator pigheadedness” and the failure to respond adequately to complaints.

Update: Kevin B. O’Reilly responded to Megan’s post with a link to an excellent article he wrote for American Medical News. His article reports:

In July, the commission issued a sentinel event alert on disruptive behavior that said “intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. … Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions.”

The commission’s alert cited research showing such behavior impedes communication among the health care team and can harm patients. A spokesman said the commission was contacted by the AMA and is reviewing the Association’s requests.

In principle it makes sense to attempt to reduce disruptive behavior, but definitions including “condescending language or voice intonation” are overly vague and risks taking this too far. The article presents some valid objections raised at an AMA meeting:

“The definition is very important,” said Stephen L. Schwartz, MD, a delegate for the Pennsylvania Medical Society. “Intimidating colleagues is wrong; everyone would agree with that. But let me point out that intimidation is in the eye of the beholder. If I ask someone a question and they feel intimidated, did I intimidate them?”

He and other delegates expressed concern that some health care organizations are using disruptive behavior policies to retaliate against physicians who are outspoken about quality of care. When “we say something about it, we are now titled disruptive physicians,” Dr. Palamara said.

Jay A. Gregory, MD, a general surgeon and chair of the AMA Organized Medical Staff Section Governing Council, said the commission’s definition is workable. But the new standard allows health care entities too much latitude with their own definitions. It is imperative, he added, that medical staffs exert control over any complaints against physicians.

Other delegates also said the rule can be used against physicians who have competing economic interests.

Yesterday I wrote about the conspiracy theories regarding Barack Obama’s birth, beginning with a link to Marc Ambinder and followed by links to other sources which provide evidence verifying that Obama is Constitutionally eligible to be president. Marc Ambinder has a follow up post today:

Since I baldly asserted that Barack Obama was provably a citizen and provably eligible to be president, several readers have written to ask me how I know this to be true.

Well, his birth certificate is valid, for one thing; it’s survived scrutiny and has been sanctioned as valid by the legal authority empowered to sanction such things. A conspiracy to cover this up is — would be — preposterous.

A thinner version of the claim holds that Obama is a citizen, but not a natural born or naturalized citizen and this constitutionally ineligible. This claim rests on a fairly tendentious argument about Obama’s father and mother. Obama Sr., wasn’t a citizen; therefore, his son could not have been born to two U.S. citizens; to be a naturalized citizen, both parents have to be U.S. citizens. Also: the law requires citizen-parents to have spent a certain length of time in the state; Obama’s mother was a woman of the world.

But the two-citizen parent rule, which is no longer in effect, applied to people born outside the U.S. Obama was born in 1961 in Hawaii, a U.S. state since 1959; (had he been born earlier, it wouldn’t matter — U.S. law granted natural born citizenship to every Hawaiian born after 1900.)

Of course, as Ambinder I’m sure is aware (assuming he has heard from the same types of conspiracy nuts I have), the basic facts of the case are denied by the conspiracy theorists. Although Obama’s actual birth certificate has been examined and verified as legitimate by impartial sources, they continue to claim that it has not. Some even deny the fact that Obama was born in the United States despite evidence he was, including a newspaper announcement in the Honolulu Advertiser.

For the conspiracy theories to be true, and all the available evidence to be false, it would take a remarkable conspiracy dating back to 1961. Obama’s family, or some other party, would have had to have the motivation and ability to place such newspaper announcements and forge a birth certificate. Even more remarkably, such conspirators back in 1961 would have had to think that a child born of a racially mixed couple would one day even have the possibility of being elected president of the United States.

The likelihood of such a conspiracy is about as low as the likelihood that the moon missions were staged on a Hollywood stage or in an isolated desert.

Update: With the Supreme Court deciding whether to hear the case tomorrow, we are certain to hear even more from the conspiracy theorists. A decision by the Supreme Court not to hear the case would be taken as evidence that the conspiracy has reached the highest levels of government. In the unlikely even they decide to merely hear the case, this will be spun as evidence for the validity of their claims.

That’s the wonder of conspiracy theories. Regardless of what happens in the real world, the conspiracy theorists always have more material to use to fuel their fantasies.

Two sides of the health care debate can be seen in this exchange. Andrew Sullivan quotes Ezra Klein:

In 2006, adjusted for purchasing power, the United Kingdom spent $2,760 per person on health care. America spent $6,714. It’s a difference of almost $4,000 per person, spread across the population. That’s $4,000 that can go into wages, or schools, or defense, or luxury, or mortgage-backed securities. And there’s no evidence that Britain’s aggregate outcomes are noticeable worse. But they do say “no” a lot more than we do. Their system refuses to pay high prices for medical technologies and pharmaceuticals that it judges insufficiently effective. They’ve forced themselves to make choice, because they have something we don’t have: A global budget. They are willing to spend a certain number of dollars (well, pounds) on health care each year, and no more than that. If resources aren’t unlimited, then choices need to be made. It’s not quite correct to say that those choice will mean letting someone die, but they do mean putting limits on what we will spend to keep them alive.

One reason I’m a conservative is the British National Health Service. Until you have lived under socialism, it sounds like a great idea. It isn’t misery – although watching my parents go through the system lately has been nerve-wracking – but there is a basic assumption. The government collective decides everything. You, the individual patient, and you, the individual doctor, are the least of their concerns. I prefer freedom and the market to rationalism and the collective. That’s why I live here.

Philosophically I sympathise with Andrew Sullivan. Pragmatically we cannot ignore these differences in spending, especially considering the large number of American who are uninsured or under-insured.

The answer is somewhere in between the extremes of the far left and right. Having the government simply stay out of health care is not the answer as our system is unsustainable. That does not mean imitating the British model is the solution. We need a uniquely American model which might learn from the British system and other foreign systems but which still respects freedom of choice (even if such choice cannot be absolute). Fortunately the British system is not really on the table here.

Jonathan Chait also prefers a solution different from the British system and responds to Andrew Sullivan by looking from the perspective of adopting the American system:

Andrew is completely missing the point. Nobody is proposing to import the British health system to America. But the conservative habit of pointing out that getting health treatment in the U.S. is better than getting it in the U.K. (as long as you have health insurance, that is) tells us nothing. Is American health care nearly three times better? Suppose you offered every Brit a chance to pay almost three times the cost of what they’re currently paying for health care so they have an American-style system. Oh, and part of the bargain is that they have to accept a one-in-seven chance of having no insurance at all. How many of them would take it? Not very many, I’d say.

Ezra looks further at rationing, referring to an article in The New York Times on the British system:

The New York Times has a front page story today on the British system of rationing. It’s a long read, but an important one. And right up towards the top, you see why. The British system has made a choice. They have valued six months of life at $22,750. That’s all they can afford, they say. So here’s the question: In a government system in the US, should the government be on the hook for more than that? If six more months of life — not a cure, but a six month reprieve– would cost $50,000, should we pay for that, keeping in mind that that money is coming from priorities like education and food stamps and wages increases? Or should we have limits? Should the system itself ration?

A better system would allow people to purchase health insurance policies that reflect their own evaluation of how much an extra bit of life should cost. Some may choose gold-plated policies that pay for nearly any new treatment. Others may decide that it is more important to save money to give to their heirs than to try to purchase a few extra months of life that an expensive policy might provide. In other words, the “rationing” decision would made by individuals rather than by bureaucratic boards eager to protect the pocket books of taxpayers.

Sounds great in principle–if only everyone could afford coverage without risk of losing it when needed.